Extent of prostate cancer treatment harms revealed in new study

Every so often there is an urgent call for a national prostate cancer screening programme to be introduced, usually following the diagnosis of a high-profile person with the disease.

But there is good reason that most countries (Lithuania and Kazakhstan being the only exceptions) don’t have national screening programmes. Overtreating a cancer that has little chance of progressing – or of progressing rapidly – can lead to signficant harms. Half of men aged 90 and over have prostate cancer, and, as the saying goes: “More men die with prostate cancer than because of it.”

A recent study in the journal Jama Oncology highlights the potential long-term harms of overtreatment, and offers new insights into the continuing debate about prostate cancer screening and treatment.

Prostate cancer is one of the most common cancers affecting men. Treatment, while often life saving, can lead to serious complications, such as loss of bladder control, sexual dysfunction and even secondary cancers.

Over the years, experts have debated how to balance the advantages of early diagnosis through prostate-specific antigen (PSA) testing against the risks of overdiagnosing and overtreating cancers that may never have caused harm. This new study adds crucial evidence to that discussion.

Researchers analysed data from two major prostate cancer prevention trials, linking them with Medicare health records to track outcomes for over 29,000 participants. Among these, nearly 4,000 men were diagnosed with prostate cancer. Of this group, 655 underwent surgery to remove the prostate (prostatectomy), 1,056 received radiotherapy, and 2,235 did not receive treatment.

The study followed these men for an average of ten years, comparing the rates of complications between treated and untreated groups. The results were striking.

Men who underwent prostatectomy were seven times more likely to experience urinary or sexual complications than those who were untreated. Common issues included incontinence, erectile dysfunction and blockages in the urinary system. In severe cases, these complications required secondary procedures, such as penile implants or artificial urinary sphincters.

The researchers also found that radiotherapy was linked to a threefold increase in urinary or sexual complications. Specific radiation-related issues, such as inflammation of the bladder (radiation cystitis) or bowel (radiation proctitis), were rare in untreated men but occurred in around five cases per 1,000 person-years in those receiving radiotherapy.

Patients who had radiotherapy were also three times more likely to develop bladder cancer compared with untreated men.

After 12 years, 61% of men who had surgery and 42% of those who received radiotherapy experienced at least one treatment-related complication, compared with only 24% of untreated men.

What does this mean for men diagnosed with prostate cancer?

The study emphasises the importance of tailoring prostate cancer treatment to the individual.

Prostate cancer often grows slowly, and in many cases, it may not require immediate treatment. For low-risk cancers, active surveillance — closely monitoring the cancer without treating it unless it shows signs of progression — can help avoid unnecessary complications. However, for men with high-risk cancers, the potential benefits of treatment, including a better chance of survival, may outweigh the risks.

The study also reignites the debate around PSA screening, a simple blood test that can detect prostate cancer early. While PSA testing can save lives by identifying cancers at an early stage, it can also lead to “false positives” (where a test incorrectly suggests cancer) or the detection of slow-growing cancers that might never have caused harm. These false alarms often lead to treatments that come with serious side-effects –– as vividly illustrated by this study.

However, advancements in technology are improving how prostate cancer is detected and managed. Tools like prostate-specific MRI scans and new biomarkers can help distinguish aggressive cancers that need immediate treatment from less harmful ones. These innovations are transforming the landscape of prostate cancer care, allowing for more precise and personalised approaches to screening and treatment.

This new research provides a clearer picture of the trade-offs involved in prostate cancer treatment, making it easier for men to make informed decisions about their care. National and international guidelines increasingly emphasise the need for personalised approaches, ensuring men understand the risks and benefits of screening and treatment.

By building on these insights, smarter, safer strategies for managing prostate cancer can continue to evolve, improving outcomes and preserving the quality of life for millions of men.

Steffen Rausch does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.